Excellus BCBS:Healthy Blue Copay

Excellus BCBS:Healthy Blue Copay A nonprofit independent licensee of the Blue Cross Blue Shield Association Summary of Benefits and Coverage: What this Plan Covers & What it Costs MONROE COUNTY Coverage Period: 01/01/2014-12/31/2014 Coverage for: Ind/Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at excellusbcbs.com or by calling 1-800-499-1275. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $0 Individual / $0 Family, In Network $500 Individual / $1500 Family, Out of network Does not apply to Preventive Care. No. Yes, $4200 Individual / $12600 Family Premiums, balance-billed charges, and health care this plan doesn t cover. No. Yes. See www.excellusbcbs.com or call 1-800-499-1275 for a list of participating providers. No. You don t need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page [4 or 5]. See your policy or plan document for additional information about excluded services. Questions: Call 1-800-499-1275 or visit us at excellusbcbs.com HealthyBlue 25-0 If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at www.cciio.cms.gov or call 1-800-499-1275 to request a copy. ID: 78124EX0237322-04 SWI: 76884-10/31/2013 1 of 8

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-network Adult $25.00 copay Child No Your Cost If You Use an Out-ofnetwork Adult 20% coinsurance Child 20% coinsurance Specialist visit $40.00 20% co-insurance ------none------ Other practitioner office visit Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Acupuncture $40.00 Chiropractic $40.00 No X-Ray $40.00 copay Lab Services No Acupuncture 20% co-insurance Chiropractic 20% co-insurance Adult Physical 20% co-insurance Well Child No Adult Immunizations 20% co-insurance 20% co-insurance ------none------ Imaging (CT/PET scans, MRIs) $40.00 20% co-insurance ------none------ Limitations & Exceptions Child up to age 19 for In-Network s Acupuncture 10 Visit(s) per year Adult Physical 1 Visit(s) per year 2 of 8

Common Medical Event Services You May Need Your Cost If You Use an In-network Your Cost If You Use an Out-ofnetwork Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at excellusbcbs.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Child copay No Retail Prescription $5.00 Mail Order Prescription $10.00 Retail Prescription $25.00 Mail Order Prescription $50.00 Retail Prescription $50.00 Mail Order Prescription $100.00 Retail Prescription $50.00 Not Covered Not Covered Not Covered Not Covered Child copay up to age 19 30 day retail supply 90 day mail order supply 30 day retail supply 90 day mail order supply 30 day retail supply 90 day mail order supply Facility fee (e.g., ambulatory surgery center) $75.00 20% co-insurance ------none------ Physician/surgeon fees No 20% co-insurance ------none------ Emergency room services $75.00 $75.00 ------none------ Emergency medical transportation $75.00 $75.00 ------none------ Urgent care $40.00 20% co-insurance ------none------ Facility fee (e.g., hospital room) $150.00 20% co-insurance ------none------ Physician/surgeon fee No 20% co-insurance ------none------ After initial fill, prescription must be filled by a participating Specialty Pharmacy. Specialty drugs are not eligible for mail order. 3 of 8

Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an In-network Your Cost If You Use an Out-ofnetwork Mental/Behavioral health outpatient services $40.00 20% co-insurance ------none------ Mental/Behavioral health inpatient services $150.00 20% co-insurance ------none------ Substance use disorder outpatient services $40.00 20% co-insurance ------none------ Substance use disorder inpatient services $150.00 20% co-insurance ------none------ Prenatal and postnatal care Prenatal No Postnatal No Prenatal 20% coinsurance Postnatal 20% coinsurance Limitations & Exceptions ------none------ Delivery and all inpatient services No Physician 20% co-insurance Facility 20% coinsurance Anesthesia No ------none------ Home health care No 20% co-insurance 40 Visit(s) per year Rehabilitation services Outpatient $40.00 Inpatient $150.00 20% co-insurance Outpatient 45 Visit(s) per year Inpatient 60 Day(s) per year Habilitation services $40.00 20% co-insurance 45 Visit(s) per year Skilled nursing care $150.00 20% co-insurance 45 Day(s) per year Durable medical equipment 20% co-insurance 20% co-insurance ------none------ Hospice service No 20% co-insurance Family Bereavement 5 Visit(s) per year Eye exam $40.00 20% co-insurance 1 per 12 month Period Glasses $60 Allowance $60 Allowance 1 per 12 month Period Dental check-up Not Covered Not Covered ------none------ 4 of 8

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Dental Care (Adult) Long term care Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric Surgery Chiropractic care Hearing aids Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-499-1275. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Customer Service at 1-800-499-1275. For group health coverage subject to ERISA, you can contact your plan at 1-800-499-1275. You can also contact the Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. If coverage is insured, you can contact New York State Department of Financial Services at 1-800-342-3736 For non-federal governmental group health plans and church plans that are group health plans, call 1-800-499-1275. If coverage is insured, you can contact New York State Department of Financial Services at 1-800-342-3736 Additionally, a consumer assistance program can help you file your appeal. Contact Community Health Advocates, the State s consumer assistance program, at 1-888-614-5400 or at www.communityhealthadvocates.org. 5 of 8

Does This Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. Does This Coverage Meet The Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the "minimum value standard". This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Español: Para obtener asistencia en Español, llame al 1-800-499-1275. Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-499-1275. ĬŁ: Ɓƛ ƀĭłƃĭƨ, 卄 ǧœǘĩẩā 1-800-499-1275. Dine: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-499-1275. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

Excellus BCBS:Healthy Blue Copay Coverage Period: 01/01/2014-12/31/2014 Coverage Examples Coverage for: Ind/Family MONROE COUNTY Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays: $7,350 Patient pays: $190 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $0 $40 $0 $150 $190 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $3,920 Patient pays: $1,480 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $0 $1,440 $0 $40 $1,480 Questions: Call 1-800-499-1275 or visit us at excellusbcbs.com If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at www.cciio.cms.gov or call 1-800-499-1275 to request a copy. 7 of 8

Excellus BCBS:Healthy Blue Copay Coverage Period: 01/01/2014-12/31/2014 Coverage Examples Questions and answers about the Coverage Examples: Coverage for: Ind/Family MONROE COUNTY Plan Type: PPO What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 1-800-499-1275 or visit us at excellusbcbs.com If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at www.cciio.cms.gov or call 1-800-499-1275 to request a copy. 8 of 8